Prevalence and Determinants of Depression, Anxiety, and Stress Among Secondary School Students

Background: Adolescence represents a critical period characterized by extensive changes across various domains. While some of the changes and behaviors that emerge during this period can have detrimental effects on adolescents' present and future health, mental health disorders continue to constitute a leading cause of morbidity among young individuals. Objective: Assess the prevalence and determinants of depression, anxiety, and stress among secondary school students in Saudi Arabia. Methods: This analytical cross-sectional study utilized an online questionnaire to collect responses from secondary school students in Saudi Arabia. The Arabic version of the Depression, Anxiety, and Stress Scale - 21 Items (DASS-21) was used to measure depression, anxiety, and stress levels. Data were analyzed using IBM Statistical Package for the Social Sciences software (SPSS, version 29.0, IBM Corp., Armonk, NY, USA). The study included 702 participants. Results: The prevalence of anxiety was 35.2%, followed by depression (30.8%) and stress (14.7%). Females had significantly higher anxiety and stress scores than males (P=0.004, and P=0.011, respectively). Students who were bullied in the last 30 days had significantly higher depression, anxiety, and stress scores than those who were not bullied (P<0.001 for all). Participants who experienced physical assault in the last 12 months had significantly higher depression, anxiety, and stress scores than those who did not (P<0.001 for all). Participants who had had fights in the last 12 months had significantly higher depression (P=0.004) and anxiety (P<0.001) scores than those who did not. Participants who felt unsafe on the way to school had significantly higher depression, anxiety, and stress scores than those who did not (P<0.001 for all). Conclusion: The study revealed prevalence rates of depression (30.8%), anxiety (35.2%), and stress (14.7%) among secondary school students in Saudi Arabia. The study highlights the importance of addressing social stressors such as bullying and physical assault and promoting a safe and supportive school environment to prevent mental health disorders in this population.


Introduction
Adolescence is a period of remarkable change on all levels, biological, physiological, and psychological [1]. Unfortunately, some of the changes and behaviors that appear during this period can be detrimental to adolescents' current and future health [2]. The importance of this age group is emphasized in the fact that adolescents represent a high proportion of the total population. In fact, those under 25 years old constitute 39.4% of the population in the Saudi Arabia region [3]. In fact, in Saudi Arabia, one-fifth of the population is between 10-19 years [3]. anxiety followed by avoidance of an object or situation that poses no danger" [10]. Stress on the other hand is represented in feelings of emotional strain and unease when faced with challenging situations [11].
According to "Maternal, child and adolescent mental health," a technical paper from the World Health Organization (WHO), the estimated prevalence of mental health disorders in adolescents is 15%-36% [12]. An analysis of data from the Global School-based Student Health Survey (GSHS) in 19 low-and middleincome countries, including the United Arab Emirates, Jordan, Lebanon, and Morocco, found that 35% of all participating students had symptoms of depression [13]. In Saudi Arabia, the estimated prevalence of depression was reported to be 30% in Riyadh city [14]. Another study in Qassim found that among students, 34% were mildly depressed, 24.6% were moderately depressed, 10.4% were severely depressed, and 5.0% were extremely severely depressed. For anxiety, 34.1% had mild anxiety, 19.5% had moderate anxiety, and 9.8% had severe anxiety [15].
Mental health disorders are on the rise, and the consequences they can have on young people are monumental. Literature shows that depression and anxiety are the most common disorders in this age group. However, data in the Arab world is still lacking. In Saudi Arabia, different studies show a wide range of estimates for the prevalence of depression and anxiety. Furthermore, the significance of some of the determinants showed variability between studies, and others were not explored in different populations. Therefore, we conducted the present study to add to the body of evidence in order to inform public policies and to develop and implement culturally appropriate preventive interventions. The current study aimed to assess the prevalence and determinants of depression, anxiety, and stress among secondary school students in Saudi Arabia.

Study design
This study employed an analytical cross-sectional design, utilizing an online questionniare to collect responses from secondary school students in Saudi Arabia. The Arabic version of the Depression Anxiety Stress Scale (DASS-21) [16], a validated tool for measuring depression, anxiety, and stress levels, was utilized.

Study population
The study included male and female secondary school students in Saudi Arabia. The inclusion criteria comprised all secondary school students in Saudi Arabia, encompassing students from both governmental and private schools. The exclusion criteria encompassed students attending evening schools, special-needs education schools, and students with intellectual disabilities.
Using EPI-INFO 7 software, a minimum sample size of 384 secondary school students was determined. Assuming a prevalence of 50% for depression, anxiety, and stress, with a precision of 5% and a confidence level of 95%, the final sample size was set at approximately 450 students, accounting for a 20% non-response rate. Convenient sampling was employed to recruit the participants. In the present study, we have collected a substantial total of 702 responses to enhance the study's statistical power and achieve a more comprehensive representation at a national level.

Data collection
Data were collected using a self-administered questionnaire that utilized validated tools to measure rates of depression, anxiety, stress, and health behaviors among students. In addition to the adopted tools, age, gender, self-reported height, and weight were obtained from the participants. The target population were reached using a social media platform (WhatsApp) using a link to the online questionnaire. The data collection took place during the month of June 2023.
The Global School-Based Student Health Survey (GSHS), a self-administered questionnaire developed by the WHO, was used to obtain data on young people's health behavior and protective factors related to morbidity and mortality [16]. We used a modified version of the GSHS questionnaire based on a review of the literature and expert opinions. Behavioral questions included sedentary leisure behavior, frequency of hunger, sleep during weekdays, frequency and type of bullying, frequency of physical attacks and fights, and absenteeism due to safety concerns.
The Depression, Anxiety, and Stress Scale-21 (DASS-21) were used to measure negative emotional states of depression, anxiety, and stress [17]. The anxiety scale corresponded to symptom criteria for anxiety disorders, except for generalized anxiety disorder. The depression scale corresponded to mood disorders, and the stress scale corresponded to the DSM-IV symptom criteria for general anxiety disorder (GAD). Subjects were asked to rate the extent to which they had experienced a group of states associated with the three disorders over the past week, using 4-point severity/frequency scales.

Statistical analysis
The data were analyzed using the Statistical Package for the Social Sciences software (IBM Corp. Released 2021. IBM SPSS Statistics for Macintosh, Version 29.0. Armonk, NY: IBM Corp). Continuous variables were assessed for normal distribution using the Shapiro-Wilk test. Since the test revealed that all continuous variables were skewed, median and interquartile range (IQR) were used. Categorical variables were presented in frequency tables and percentages.
For continuous variables, the strength of association was determined using Spearman's correlation coefficient. Differences in DASS-21 subscales between groups of categorical variables were tested using non-parametric tests, including Mann-Whitney and Kruskal-Wallis tests, as appropriate. Statistical significance was considered at a P-value < 0.05.

Ethical considerations
The study protocol was approved by a research ethics committee, and all participants were informed about the study's purpose. Written consent was obtained, and confidentiality was assured. Participation was voluntary, and participants were free to withdraw from the study at any time. There was no conflict of interest. All responses were anonymous and used solely for research purposes. The current study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines to ensure comprehensive and transparent reporting of the observational research.

Results
The median age of participants was 18, with an IQR of 17-18. The median body mass index (BMI) was 22.27, with an IQR of 19-26.14. Among the participants, 79.5% were females and 20.5% were males. The majority of participants were in their third year of school (70.7%). The majority of participants had a normal BMI (46.5%). See the detailed results of sociodemographic characteristics in (Table 1).
Excluding students who had normal scores in the subscales of DASS-21, anxiety had the highest prevalence at 35.2%, followed by depression at 30.8%, and stress at 14.7%. Notably, 7.8% of students showed severe or extremely severe levels of anxiety, while 1.3% showed severe or extremely severe levels of depression. None of the students showed severe or extremely severe levels of stress. The levels of depression, anxiety, and stress are demonstrated in detail in (Figure 1).   (Table 2).
From the analysis, it was observed that three factors had correlation coefficients above 0.  (Table 3).

Question Answers Number Percentage
During the last 30 days, how many times did you feel hungry because there isn't enough food at home?   Several significant differences were observed in DASS-21 subscale scores between groups. Females had significantly higher anxiety (p = 0.004), and stress (p = 0.011) scores than males. While not statistically significant, depression was higher among females (p = 0.052). Participants in their first year of school had lower depression (p = 0.015) and stress (p = 0.025) scores than those in their third year, while those in their second year had higher stress (p = 0.025) scores than those in their third year. Students with normal BMI had lower anxiety (p < 0.001) and stress (p = 0.002) scores than those who were underweight, overweight, or obese. For further details, see the resutls in (Table 4).
Students who were bullied in the last 30 days had significantly higher depression (p < 0.001), anxiety (p < 0.001), and stress (p < 0.001) scores than those who were not bullied. Students who experienced physical assault in the last 12 months had higher depression (p < 0.001), anxiety (p < 0.001), and stress (p < 0.001) scores than those who did not. Participants who had fights in the last 12 months had higher depression (p = 0.004) and anxiety (p < 0.001) scores than those who did not. Participants who felt unsafe on the way to school had higher depression (p < 0.001), anxiety (p < 0.001), and stress (p < 0.001) scores than those who did not. Finally, participants who reported being hungry due to lack of food in the last 30 days had higher depression (p = 0.003), anxiety (p = 0.004), and stress (p < 0.001) scores than those who did not report hunger. See the related resutls showed in (Table 5).

Discussion
This study investigated the prevalence and determinants of depression, anxiety, and stress among secondary school students in Saudi Arabia. The prevalence rates were found to be 35.2% for anxiety, 30.8% for depression, and 14.7% for stress. The results of the present study align with previous studies conducted in the region [1,14]. However, the present research results also oppose certain prior studies conducted in Saudi Arabia. For instance, a study conducted by Al-Shehri et al. reported a much higher prevalence of depression and anxiety which was found in 42.9% and 46.6% of secondary school students, respectively. However, the stress percentage found in their study (19%) was quite similar to our findings [18]. On the other hand, lower rates were reported in Jeeluna, a national school-based cross-sectional study, that examined the underlying risk factors for feeling so sad or hopeless and for feeling worried among a sample of 12,121 intermediate and secondary school students in Saudi Arabia. The authors utilized a self-administered questionnaire to ascertain the prevalence rates of depression and anxiety, which were found to be 14% and 6% respectively [19]. Higher rates in our study can be attributed to the difference in the target population which constituted secondary school students only.
In the current study, it was found that 7.8% of the students exhibited severe or extremely severe levels of anxiety, whereas 1.3% displayed severe or extremely severe levels of depression. The findings were lower than a previous study conducted in the Qassim region that assessed levels of depression and anxiety in 1,245 students, using the Patient Health Questionnaire (PHQ-9) and the General Anxiety Disorder (GAD-7) survey tool. They found that those who were not depressed were 26.0%, the mildly depressed were 34%, the moderately depressed were 24.6%, whereas 10.4% were moderately severely depressed and 5.0% were severely depressed. For anxiety, 36.5% did not have anxiety, 34.1% had mild anxiety, 19.5% showed moderate anxiety, and 9.8% were classified as severe anxiety. Females were higher than males in all categories of depression and anxiety [15]. In another study, a total of 545 female students were recruited, and it was found that 73.4% of them exhibited symptoms associated with at least one of the three disorders under investigation. Furthermore, 50.1% of these students presented symptoms indicative of at least two of the studied disorders. The rates of symptom manifestation for depression, anxiety, and stress were found to be 41.5%, 66.2%, and 52.5% respectively. The majority of symptoms exhibited by individuals were of mild to moderate severity [20].
The present study also revealed a gender disparity in the prevalence of mental health issues, with females reporting higher levels of depression, anxiety, and stress compared to males. This finding resonates with existing literature on gender differences in mental health outcomes during adolescence. A study conducted by Al-Kaabi et al. reported that female students were more likely to experience depression than their male counterparts. Furthermore, they showed that bad personal relationships were the most significant predictors of depression [21]. The greater incidence rates seen in females may be linked to a variety of variables, including heredity, biological factors, psychological factors, and behavioral factors [22]. Similarly, a crosssectional study conducted on just female participants from Taif reported that an estimated prevalence of 42.9%, 54.9%, and 23.1% for depression, anxiety, and obsessive-compulsive symptoms, respectively, and 64.7% had symptoms of the three disorders. Furthermore, the study found that 64.7% of the participants exhibited symptoms associated with all three disorders. The researchers discovered noteworthy positive associations between the score for depression and both the score for anxiety as well as the score for obsessive-compulsive symptoms [23]. Furthermore, comparable to our results which showed higher scores of depression, anxiety, and stress among females, Jeeluna study revealed that females exhibited a higher prevalence of symptoms related to depression and anxiety compared to males [20]. In a cross-sectional study comprising 1,723 male students, it was observed that 59.4% of participants exhibited at least one of the three disorders, 40.7% presented with at least two disorders, and 22.6% were diagnosed with all three disorders. Furthermore, it is worth noting that a significant proportion of the participants, specifically 38.2%, exhibited symptoms of depression. In the same study, a considerable percentage of the participants, amounting to 48.9%, reported experiencing anxiety, while 35.5% indicated the presence of stress [1].
In the present study BMI was significantly related to anxiety; however, BMI did not achieve statistically significant relationship with depression or stress. While the relationship between higher BMI and likelihood of depression, anxiety, and stress has been shown in previous studies [24,25]. However, high BMI might not be the direct cause of depression, anxiety, or stress, rather it is plausible that other pathways and experiences contribute to the development of depression indirectly. For instance, stressful life events, such as peer victimization and weight-based teasing, could potentially biologically predispose young individuals to depression. Consequently, these factors may serve as contributing factors that lead to depression in obese youth [26].
The current study additionally examined diverse social stressors and their impact on the onset of depression, anxiety, and stress. The findings indicated a statistically significant correlation between experiencing bullying within the past 30 days, being subjected to physical assault within the previous 12 months, and being absent from school due to feelings of insecurity and experiencing symptoms of depression, anxiety, and stress (p<0.001). Previously, a study by AlBuhairan et al. also reported an association between being bullied and depression among Saudi students. Furthermore, they showed that out of 9,073 students, 26% were bullied in the last 30 days and one out of three experienced physical violence in past one year [27]. Apart from these social stressors, various other factors such as poor relationship with peers and family, not being happy with body image, emotional abuse, and physical abuse have been implicated in the development of anxiety and depression [14].
One of the strengths of this study is its large sample size and the use of standardized assessment tools, namely, DASS-21 to measure depression, anxiety, and stress, and GSHS self-administered questionnaire developed by WHO to measure health behavior. The study also considered several sociodemographic and social stressor variables, providing a comprehensive analysis of the factors associated with mental health outcomes in this population. However, there are some limitations to this study. For instance, data on potential confounding variables, such as family history of mental illness or prior mental health treatment, were not included. Moreover, the predominant representation of females in the sample could have potentially resulted in over-reporting of symptoms and consequently inflated the prevalence rates of depression, anxiety, and stress.

Conclusions
This study aimed to investigate the prevalence and determinants of depression, anxiety, and stress among secondary school students in Saudi Arabia. The results indicate that anxiety had the highest prevalence at 35.2%, followed by depression at 30.8% and stress at 14.7%. Additionally, the study found that females had higher depression, anxiety, and stress scores than males. Furthermore, students who experienced bullying, physical assault, and fights had higher depression, anxiety, and stress scores than those who did not. Time spent sitting was also found to be moderately correlated with depression, anxiety, and stress.
The findings suggest that schools and policymakers should prioritize creating safe and supportive environments for students, providing resources and support for students experiencing mental health issues, and implementing preventive interventions to reduce the prevalence of these disorders. Future research should investigate the effectiveness of interventions aimed at reducing the prevalence of mental health disorders among secondary school students in Saudi Arabia.